Principle 6

Don't forget about the rest of the patient and his/her needs. These include hydration and nutrition. Patients that are requiring positive pressure ventilation have been done are the common every day practice that does not have a fancy ventilator. It can be done by using intravenous drip pentobarbital sodium at 1 mg/kg/hr or other medications such as ketamine, lidocaine and morphine, Propofol, isoflurane, dometore and other mixtures of medications. Don't think it can't be done. I do not have the right drugs or equipment. I have never done this before. It can't work. I am here to tell you it can work. We had a family of four ventilate their puppy though a severe bout of centroneurogenic pulmonary edema following a choking episode in the yard. They took turns squeezing the AMBU bag connected to the endotracheal tube and euthanasia sodium pentobarbital was diluted severely down and added to the iv fluids to keep the dog asleep and not fighting the ET tube that remained in place with an occasional change every 6-12 hours. After the 5th hour of by-hand ventilation with the AMBU bag connected to a PEEP Valve and oxygen at 3-4 LPM the dogs breath sounds improved greatly and weaning was able to start commencing the following morning. He was able to be extubated the following day and he recovered.

Several Cases for Discussion if Time Permits

2 mo old M Jack Russell – stepped on by a horse – sustaining severe pulmonary injury, shock, suspected hemoabdomen, liver injury. The dog was intubated and ventilated and placed on a mechanical ventilator. Resuscitation continued with fluid and Oxyglobin support. A blood transfusion was also given and the dog was maintained on a BIRD anesthetic ventilator for 36 hours and gradually weaned off and onto nasopharyngeal oxygen. He made a complete recovery after another day of hospitalization, discharge and continued care by the RDVM.

Timber

2 yo German Sheppard Dog - Run over in the caudal thoracic region by a ¾ pickup truck, sustaining significant pulmonary contusion hemopneumothorax, hemoabdomen, shock, secondary vena cava obstruction caudally. Underwent resuscitation, chest tube placement, autotransfusion, DPL, exploratory celiotomy, liver packing and hemostatic agent application, continued autotransfusion, noninvasive support ventilation after extubation, CPAP with NP oxygen, enteral nutrition, and he made a complete recovery after an episode of severe ascities with the drainage of 3 L of fluid.

Noah

German Sheppard 6 month old male dog with severe pneumonia that had been to see several veterinarians. Each had prescribed antibiotics and expectorants. Subcutaneous fluids were also being given as prescribe by one of the veterinarians. Then a few days before admission he was hospitalized at another hospital and was given oxygen by cage, nebulization by cage and mask, and iv antibiotics of cephazolin, and iv fluids for two days. Despite this care he was determined to be getting much worse by the referring veterinarian. On admission radiographs revealed significant alveolar bronchograms throughout the ventral aspects of multiple lung lobes, he had a fever of 102.9 and was very depressed. He was showing an increase in respiratory rate and effort and breath sounds were decreased and there were wheezes bilaterally. The IV catheter site was slightly red and inflamed. On placing him on blow by oxygen there was some decrease in effort but rate was still increased. Based on the clinical signs it was recommended to perform some non-invasive ventilation to start after providing sedation and then performing RSI and after intubation to gain culture, cytology, Gram's stain. Then is was agreed upon to place him on the ventilator for a few hours and see if we could improve arterial gases, radiographs, etc., The owners agreed on this approach despite the poor prognosis that was provided. There was a suspicion that viral distemper might have been the cause of the pneumonia initially. The IV catheter site was cultured and the catheter changed. Labs were drawn and a left shift with 28,000 WBC and some toxic granulocytes as noted. Following IPPV with a bag-valve – mask the dog was anesthetized with hydromorphone, ketamine and acepromazine. When the trachea was intubated as sterilely as possible and a deep bronchial suctioning was completed. There was very thick secretions present and the Gram's stain revealed many rods and cocci and cytology revealed many degenerating neutrophils as well as others more normal in appearance. A culture was submitted. Based on the amount of exudate present within the lungs it was then suggested to the owners to have a temporary tracheotomy performed to allow for aggressive tracheal toileting that would still be able to done without the dog completely anesthetized which would decrease mucociliary clearance and suppress the immune system. The owners agreed and the tracheostomy was completed. While this was done PEEP at 5 cm H2O and a lung protective strategy was followed. An occasional sigh ventilation at 40 cmH2O was performed and continued for an hour post tracheotomy. Postural drainage, micronebulization with saline was gun and Amikacin was added to this at the conclusion of the ventilatory therapy. Throughout the next few days progressive improvement was observed and tracheal suctioning, micronebulization, breathing treatments with IPV and PEEP was delivered very 2-6 hours. Respiratory effort significantly improved and the suctioning was able to be discontinued after three days. It had begun as being needed several times an hour. The dogs tracheotomy tube was able to be removed on the third day and he recovered.